One Shot Medicine: The Stilted Pseudo-comprehensiveness of American Primary Care

As a Family Practitioner, I trained and I always practiced with the philosophy that my work is best done over time, in an ongoing relationship with each patient. The longer I know someone, the more they trust me and the closer they let me into their personal lives and the workings of their minds. In many cases I treat several generations of the same family. Even with a brand new patient, I often find out I know and have treated several of their relatives, and such new patients often act as if they already know me.

All that is very different from the stilted pseudo-comprehensiveness of medicine in America today.

First, those in power think that we can cover each patient’s presenting concern AND all appropriate health screenings, immunizations and other public health issues, along with the latest protected-minority-and-political-correctedness inquiries, in our typical fifteen minute visits.

“They”, whoever they are that decide coding standards, Patient Centered Medical Home standards, Meaningful Use standards, EMR workflows and the general purposes of life in medicine, have, in their inscrutable wisdom, decided that all of these items are best addressed by administering standardized, “validated” questionnaires every time we see each patient, just like even a patient with a dozen prescription medications is supposed to get a complete medication reconciliation every time they walk through the door, even for a hangnail. At twenty seconds per medication, that would take up four of our precious fifteen minutes, just for starters.

“But not all of this has to be done by the physician”, goes the refrain. “Team members, practicing at the top of their license, can do this”.

Right, have a medical assistant who never took a day of pharmacology reconcile medication lists, and trust that they know that Compazine is prochlorperazine, Trilafon is perphenazine, Phenergan is promethazine, and Thorazine is chlorpromazine. And, that metoprolol tartrate is a 12 hour drug, while metoprolol succinate is taken once every 24 hours and that bupropion comes in short, intermediate and long acting varieties.

And, right, keep telling me that a two or nine item questionnaire administered in rapid-fire fashion during check-in will outperform a trusted physician leaning forward, asking a long term patient “how are you feeling?”

And, right, tell me how much a woman with pneumonia appreciates being cornered for her overdue Pap smear when she’d rather just get an antibiotic and some cough medicine and crawl back under the covers for a few days.

And, right, tell me the local pastor is going to be forthcoming with a medical assistant he also sees in the second pew from the back of his church every Sunday as she probes his alcohol habits while pumping up the blood pressure cuff.

And, right, that new patient with anxiety and heart palpitations is going to feel much more reassured after her EKG and careful history and physical and a thorough discussion about whether or not she would want to be resuscitated if her heart were to stop suddenly.

Doctors have been doctoring for thousands of years and we have learned a few things along the way. Medical progress usually comes to practicing physicians via scientific research and from the major teaching institutions.

Since when do we really think it will come to us from bureaucrats, statisticians and other nonmedical sources?

4 Responses to “One Shot Medicine: The Stilted Pseudo-comprehensiveness of American Primary Care”

  1. 1 Elaine November 29, 2016 at 3:47 pm

    I like to think that ‘primary care’ (sounding too much like primary school for my liking) doesn’t begin to name what we do as rural docs.
    Agree wholeheartedly that taking wisdom from admin doesn’t mean that we replace our sound approaches with series of checklists. Human beings are not airplanes.
    Rural Doc in Canada.

  2. 3 Lisa November 29, 2016 at 8:54 pm

    You aren’t happy with them. Your patients are frustrated by them. Who are these theys who create the stilted lists? I wonder if the checklists make them feel safer when they visit their doctors.

  3. 4 George November 29, 2016 at 11:12 pm

    I think you’ve struck a nerve: Who are “they”? What sub-department of what department of which bureaucratic organization are they residents of? And how can we all call them on their coding decisions? In fact, this question goes for all software – and especially in the health care field.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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